Relación entre psicoterapia psicoanalítica y psicoanálisis y su implicancia en la enseñanza de la psicoterapia psicoanalítica / Relation between psychoanalytic psychotherapy and psychoanalysis and itsbnimplications in the teaching of psychoanalytic psychotherapy

Con un marco metodológico cualitativo, se realizó un estudio descriptivo, a partir del análisis de contenido de las entrevistas realizadas a seis docentes con experiencia en la formación de psicoterapia psicoanalítica, para acercarse a su comprensión sobre el problema de la relación entre psicoanálisis como tratamiento y las psicoterapias psicoanalíticas.Se concluye que no existe acuerdo respecto a la relevancia de este problema, tanto en el ámbito teórico, como en el de la formación en psicoterapia psicoanalítica, aunque se rescata la idea de que estos tratamientos se encuentran en una relación de continuidad. A partir de esto se ofrecen propuestas para orientar la reflexión y el diseño de estos programas

Using a qualitative methodological framework, the authors conducted a descriptive study based on content analysis of interviews with experienced psychoanalytic psychotherapy training teachers, in order to get closer to their understanding of the problem related to the relationship between psychoanalysis as a treatment, and psychoanalytic psychotherapies.The authors findings indicates, that there is no agreement on the relevance of this matter, neither in the theoretical realm, nor in the training of psychoanalytic psychotherapy, although the stressed idea, is that these treatments are part of a continuum

[Pasteurella multocida and Candida albicans peritonitis]. / Peritonitis por pasteurella multocida y Candida albicans.

Peritonitis is a well-known complication of peritoneal dialysis (PD) treatment. Repetitive episodes may induce an irreversible damage of the peritoneal membrane and are a frequent cause of PD drop-out. The great majority of the episodes are due to Staphylococci, Streptococci or gram- negative organisms. Unusual organisms have been reported, specially in immunosuppressed hosts. Few cases of Pasteurella Multocida (PM) have been described in PD patients. To our knowledge, we describe the first case preceding a Candida Albicans (CA) peritonitis. A review of the literature of PM peritonitis and the relation between these two microorganisms is discussed.

Peritonitis por Pasteurella multocida y Candida albicans / Pasteurella multocida and Candida albicans peritonitis

Las peritonitis son una complicación frecuente en pacientes en tratamiento condiálisis peritoneal. Las peritonitis reiteradas pueden conducir a un daño irreversiblede la membrana peritoneal que en ocasiones provoca la suspensión de la técnica.La mayoría de los episodios son producidos por Streptoccocus, Staphiloccocusy otros gérmenes gram negativos. Se han descrito mecanismos infrecuentes enpacientes inmunodeprimidos. Existen escasas referencias en la literatura sobre peritonitisproducidas por Pasteurella Multocida en pacientes en diálisis peritoneal.A continuación describimos un caso de peritonitis por Pasteurella Multocida queprecede a una peritonitis por Candida Albicans. A propósito del caso se discutiránlas peritonitis por Pasteurella Multocida y la relación entre ambos microorganismos

Peritonitis is a well-known complication of peritoneal dialysis (PD) treatment.Repetitive episodes may induce an irreversible damage of the peritoneal membraneand are a frequent cause of PD drop-out. The great majority of the episodesare due to Staphylococci, Streptococci or gram- negative organisms. Unusualorganisms have been reported, specially in immunosuppressed hosts. Few cases ofPasteurella Multocida (PM) have been described in PD patients. To our knowledge,we describe the first case preceding a Candida Albicans (CA) peritonitis. A reviewof the literature of PM peritonitis and the relation between these two microorganismsis discussed

Myofibroblastic differentiation in simple peritoneal sclerosis.

OBJECTIVE: To analyze the presence of myofibroblasts in a series of peritoneal dialysis (PD) patients with simple sclerosis and non-PD, uremic patients. Since there is a close correlation between active fibrosis and myofibroblastic differentiation we wanted to test if myofibroblasts are present in uremic, non-PD peritoneal samples. To determine if there are correlations between myofibroblastic presence and other functional and morphologic peritoneal parameters. METHODS: Biopsies were collected from three patient groups: 1) Normal control samples (n = 15) of parietal and visceral peritoneum 2) non-PD uremic patients (n = 16); and 3) uremic patients on PD (n = 32). Peritoneal morphologic and functional parameters and immunohistochemical expression of alfa-smooth muscle actin was analyzed in each case. Vascular endothelial growth factor (VEGF), bcl-2 anti-apoptotic protein, and progesterone receptor was evaluated in a subset of cases. RESULTS: Myofibroblasts were present in 56.3% of the patients with PD-related simple sclerosis. In most cases they were distributed in the upper submesothelial area. None of the biopsies from normal controls and uremic, non-PD patients showed myofibroblasts. Within the group of PD patients, myofibroblasts showed no correlation with time on dialysis, urea/creatinine MTAC, episodes of peritonitis, submesothelial thickening, hyalinizing vasculopathy or mesothelial status. In a subset of PD patients VEGF expression was observed in submesothelial fibroblastic cells. No expression of progesterone receptor or bcl-2 was observed. CONCLUSIONS: Myofibroblasts are a reliable and simple indicator of fibrosis since they appear in early stages of PD treatment and in patients with minor morphologic anomalies. They are not exclusive of patients with sclerosing peritonitis, ultrafiltration loss or long standing treatment. Their absence in non-PD, uremic patients suggest that uremia-related fibrosis takes place without a significant participation of myofibroblasts.

Pioderma periileostómico: caso clínico / Peri-ileostomic pyoderma gangrenosum: report of one case

We report a 39 years old woman with Ulcerative Colitis unresponsive to medical treatment. A total colectomy with Brooke ileostomy was performed, as the first operation. After six weeks she developed a peri-ileostomic Pyoderma Gangrenosum. She was treated by a multidisciplinary team, and after seven months with local treatment and systemic medication, the skin healed. Her bowel transit was reconstructed later with an ileoanal pouch and she was reinserted into her previous job (Rev Méd Chile 2004: 132: 747-9).

[Recurrence and spontaneous remission of nephrotic syndrome in secondary renal amyloidosis]. / Recurrencia y remisión espontánea de síndrome nefrótico en amiloidosis renal secundaria.

Secondary systemic amyloidosis (AA) occurs in association with chronic inflammatory disorders and chronic infections. Regression can occur after therapeutically induced remission of the underlying disease; spontaneous remissions has been reported infrequently. We report a 61 year-old woman, with antecedent pulmonary tuberculosis, who developed a nephrotic syndrome at the time of a respiratory infection. Renal biopsy showed secondary amyloidosis. Remission in the nephrotic syndrome appeared spontaneous, but it recurred in the course of pneumonia, and had a second spontaneous remission a maintained at present.

[Use of icodextrin for diurnal exchange in patients undergoing automatic peritoneal dialysis. Comparison with glucose solutions]. / Uso de icodextrina en el intercambio diurno en pacientes en diálisis peritoneal automática. Comparación con soluciones con glucosa.

Icodextrin (IC) is an osmotic agent that produces sustained ultrafiltration (UF) during long dwell time periods in peritoneal dialysis patients. The aim of this study was to evaluate the effects of 7.5% IC for the diurnal exchange in automated peritoneal dialysis (APD) patients and to compare them with that of 2.27% glucose solutions. Seventeen patients treated on APD during 13.9 +/- 12.7 months were included. The study was divided into three eight weeks phases. During the baseline period patients used 2.27% glucose for the daytime, second, IC 7.5% was prescribed for the day-exchange, and finally 2.27% glucose solution was used for the last eight weeks. Daytime UF increased in all patients during IC use (-53 +/- 22 to 270 +/- 304 ml/day, p < 0.01). Patients with higher peritoneal permeability capacity obtained more benefits. Daytime urea KT/V and weekly creatinine clearance (WCC) augmented significantly during IC use, but the increase of weekly urea KT/V and WCC was not significant (2.18 +/- 0.45 to 2.26 +/- 0.41 and 62.7 +/- 18 to 66.6 +/- 15 l/week/1.73 m2; respectively). On IC, nightly glucose load significantly decreased (289 +/- 82 to 266 +/- 94 g, p < 0.05), returning to previous value after withdrawal. Plasma osmolality did not change, although plasma sodium levels decreased during IC use (140 +/- 3 to 136 +/- 2, p < 0.001). Serum amylase levels significantly declined during IC use (279 +/- 151 to 29 +/- 9 U/l), returning to previous values after transfer to glucose. Peritoneal function transport parameters and peritoneal protein losses did not change. IC metabolite plasma levels increased during the use of this solution, returning to previous values after withdrawal. In conclusion, IC dialysate is an excellent alternative to glucose dialysate for the day-exchange in APD patients. Daytime UF increased in all patients, but those with higher peritoneal permeability capacity obtained more benefits. The decrease of the glucose peritoneal load overnight and the reduction for more than 50% of exposure time of the peritoneal membrane to glucose solutions, probably make IC solution a more biocompatible fluid.

Recurrencia y remisión espontánea de síndrome nefrótico en amiloidosis renal secundaria / Recurrence and spontaneous remission of nephrotic syndrome in renal secondary amyloidosis

La amiloidosis secundaria (AA) es consecuencia de gran variedad de procesos inflamatorios crónicos y la mayoría de las remisiones se producen al tratar la enfermedad de base, siendo poco frecuente la resolución espontánea. Presentamos el caso de una mujer de 61 años con antecedentes de tuberculosis pulmonar en la juventud, que desarrolla, coincidiendo con cuadro catarral, un síndrome nefrótico secundario a amiloidosis AA, que remite espontáneamente, y que recurre de nuevo en el curso de una neumonía, regresando de nuevo espontáneamente, hasta la actualidad (AU)

Uso de icodextrina en el intercambio diurno en pacientes en diálisis peritoneal automática. Comparación con soluciones con glucosa / Icodextrin in automated peritoneal dialysis. Comparisons with glucose solutions

La icodextrina (IC) es un agente osmótico que tiene la capacidad de mantener la ultrafiltración (UF) de forma sostenida durante períodos largos de tiempo. El objetivo de este estudio fue evaluar los efectos de la utilización de soluciones con IC 7,5 por ciento durante el intercambio diurno en pacientes tratados con diálisis peritoneal automática (DPA) y compararlos con los obtenidos con soluciones que contienen glucosa. Se incluyeron 17 pacientes en tratamiento con DPA durante 13,9 ñ 12,7 meses. El estudio se realizó en tres fases de 8 semanas de duración cada una. En la primera los pacientes usaron durante el intercambio diurno soluciones con glucosa al 2,27 por ciento, en la segunda soluciones con IC 7,5 por ciento y en la tercera glucosa 2,27 por ciento. La prescripción de la DPA nocturna no se modificó. La ultrafiltración diurna se incrementó en todos los pacientes durante la utilización de IC (-53 ñ 22 a 270 ñ 304 ml/día, p < 0,01), siendo los más beneficiados aquellos con mayor permeabilidad peritoneal. Los valores de Kt/V y de CCrs diurnos aumentaron significativamente durante el uso de IC; mientras que en los totales las diferencias no fueron significativas (2,18 ñ 0,45 a 2,26 ñ 0,41 y 62,7 ñ 18 a 66,6 ñ 15 l/semana/1,73 m2; respectivamente). La carga nocturna de glucosa absorbida descendió durante el uso de IC (289 ñ 82 a 266 ñ 94 g, p < 0,05), volviendo a valores similares a los previos tras su suspensión. Los niveles plasmáticos de sodio descendieron durante el uso de IC (140 ñ 3 vs 136 ñ 2, p < 0,001) aunque la osmolaridad plasmática no se modificó. La amilasa sérica disminuyó durante la utilización de IC (279 ñ 151 a 29 ñ 9 U/l, p < 0,001), volviendo a valores previos tras reiniciar la glucosa. El transporte de solutos y las pérdidas proteicas peritoneales no se modificaron. Se observó un aumento significativo de los niveles plasmáticos de IC y sus metabolitos durante el uso de IC. Concluimos que las soluciones con IC son una excelente alternativa a las que contienen glucosa para el intercambio diurno en DPA. El incremento en la UF se observó en todos los pacientes estudiados, aunque aquellos con una mayor superficie peritoneal efectiva fueron los más beneficiados. La reducción de la carga diaria de glucosa absorbida y la disminución de más del 50 por ciento del tiempo diario de exposición de la membrana peritoneal a la glucosa, la convierten probablemente en una solución más bicocompatible (AU)

Alpha replacement method for displaced peritoneal catheter: a simple and effective maneuver.

Displacement of the peritoneal catheter tip is one of the most frequent causes of catheter malfunction. As a consequence, appropriate peritoneal effluent drainage is impossible. Alternatives to catheter exchange or invasive abdominal intervention did not appear until the alpha maneuver was described by Yoshihara et al. We review our experience with this maneuver over the last 7 years. We used the alpha maneuver in 24 peritoneal dialysis (PD) patients (13 men and 11 women) with a mean age of 52 +/- 16 years. Some patients required several repeat procedures (total procedures: 32). The mean time between placement of the catheter and performance of the alpha maneuver was 6.5 +/- 7.9 months. In all patients, the technique was indicated for problems with peritoneal effluent drainage, after verification of catheter tip displacement by radiologic examination. In 6 patients, the initial maneuver was unsuccessful and had to be repeated. The first maneuver was effective in 11 of 24 cases (46%) and unsuccessful in the other 13 (54%). No differences in sex, renal disease, or age were seen between the two groups. The mean time between catheter placement and tip displacement detection was significantly lower in the cases of ineffective maneuver (2.7 +/- 4.3 months) than in those that met with success (10.8 +/- 9 months). In other words, 84% of unsuccessful maneuvers were performed in the first 3 months of catheter life. Of the 11 patients successfully treated, 6 continued on PD for 14.7 +/- 6.3 months. Two other patients were transplanted with normal-functioning catheters, and two more left PD (after 10 and 17 months) for reasons unrelated to the catheter. One patient required a catheter change owing to breakdown in the Silastic after disruption by the metallic guide, which perforated the catheter wall. The 13 ineffective maneuvers involved 7 omentum entrapments, 1 procedure that was repeated effectively 15 days later, and 5 definite failures requiring catheter change. The failure rate may therefore be considered to be 20.8%, taking into consideration that omentum entrapment should not be an indication for the procedure. We conclude that the alpha maneuver for a displaced peritoneal catheter is a simple and effective procedure that can be applied at the patient's bedside. In consequence, it should be the technique of first choice in these situations. Only when the alpha maneuver fails should invasive methods, including catheter change, be considered.

Tumor necrosis factor alpha as a uremic toxin: correlation with neuropathy, left ventricular hypertrophy, anemia, and hypertriglyceridemia in peritoneal dialysis patients.

Tumor necrosis factor alpha (TNF alpha) is usually excreted by the kidney. In dialysis patients, it accumulates. TNF alpha has been implicated in the pathogenesis of malnutrition, diabetic neuropathy, and erythropoietin resistance. We studied TNF alpha plasma levels in 49 stable peritoneal dialysis (PD) patients, with the aim of correlating those levels with the presence and severity of peripheral neuropathy, hypertrophic cardiomyopathy, and anemia. Kt/Vurea' residual renal creatinine clearance (CrC), nutritional markers, and general biochemistry were also determined. The average plasma level of TNF alpha was 67 +/- 32 pg/mL (range: 18.1-156.3 pg/mL; normal value 3-20 pg/mL). No correlation was observed between TNF alpha and KT/Vurea' but a negative correlation with CrC was seen (r: -0.37, p < 0.05). TNF alpha levels were higher in patients with neuropathy as compared to patients with normal results (72.5 +/- 32 pg/mL vs 44 +/- 22 pg/mL, p < 0.05). Patients with neuropathy also showed a lower CrC value (1.5 +/- 1.7 mL/min vs 3.9 +/- 2.6 mL/min, p < 0.01). TNF alpha levels were higher in patients with left ventricular hypertrophy (LVH) with respect to normal individuals (70.4 +/- 32 pg/mL vs 38.5 +/- 20.8 pg/mL, p < 0.05). Patients with severe LVH showed the lowest CrC value. A direct, significant relationship was found between TNF alpha levels and weekly erythropoietin dose (r: 0.41, p < 0.05). Patients with hypertriglyceridemia or taking lipid-lowering agents showed a positive linear correlation between TNF alpha and triglycerides (r = 0.7, n = 14, p < 0.05). These data suggest that accumulation of TNF alpha may contribute to the development or maintenance of some neurologic, hematologic, and cardiac complications of uremic syndrome. Loss of residual renal function conditions an increment in TNF alpha levels. These data continue to add support to the idea that TNF alpha may be considered a uremic toxin.

Stability of the peritoneal membrane in long-term peritoneal dialysis patients.

One of main challenges of peritoneal dialysis (PD) is the functional and vital long-term stability of the peritoneal membrane. Few longitudinal and controlled studies on peritoneal function have been published, and the results are somewhat contradictory. We have performed a longitudinal study with 90 patients. The overall analysis has shown that creatinine mass transfer coefficient (MTC) significantly increases and ultrafiltration (UF) capacity decreases over time. Nevertheless, urea MTC remained unaltered and MTC ratios significantly decreased after the third year. Subsequently, we examined the clinical outcomes and identified 19 patients who required peritoneal resting periods for Type I UF failure and 71 patients who did not require such a procedure. The latter patients did not show any significant functional change over time, whereas the former 19 patients showed an increase of peritoneal creatinine transport and a loss of UF capacity. These data corroborate changes in long-term peritoneal function in approximately 20% of PD patients. These changes consist of an increase in effective exchange area, peritoneal permeability, or both, accompanied by signs suggestive of mesothelial regenerative capacity loss. Infectious peritoneal injuries, especially appearing during late PD periods, are deleterious to the peritoneum. The remainder of the functional-structural changes are related to the effects of currently used dialysate. Early diagnosis, preemptive, and therapeutic measures should permit better management of long-term PD patients. The particular response to these injuries has individual characteristics that when addressed permit PD to be used long-term.

Consequences of peritonitis episodes appearing late during peritoneal dialysis (PD) in patients able to continue PD.

The lack of specific information on the peritoneal-function consequences of late peritonitis episodes, and the concern about long-term consequences of peritoneal dialysis (PD), have prompted us to study the peritoneal function of long-term PD patients after a late peritonitis episode. The question is: Is the peritoneum more vulnerable to infections, in terms of functional effects, after a long time on PD? Forty-nine patients observed from baseline to the first year of PD with no peritonitis constituted the "early" control group; 31 other patients had one episode of peritonitis in the same period. Twenty-seven patients with no peritonitis from the fourth to fifth years comprised the "late" control group; 15 other patients had one episode during the same period. The results presented here suggest that peritoneal vulnerability to infectious episodes depends on the PD stage in which they appeared. Certainly, episodes with similar aggressive capacity in terms of inflammation duration (3-4 days) happening during the fifth year led to a loss of ultrafiltration (UF) capacity that does not appear in patients who suffer an episode during the first PD year. A remarkable feature is that this UF-capacity decrease is not accompanied by the usual creatinine mass transfer coefficient increase. This fact suggests that the dependence between peritoneal-glucose-gradient maintenance and water transport has been partially modified over time on PD. In conclusion, late mild peritonitis has distinct peritoneal-function consequences relative to early peritonitis. Patients who continue PD after one late episode showed an accentuation of the usual change which happens on long-term PD, the loss of peritoneal ultrafiltration capacity.

[Acute-phase reactants in sepsis]. / Reactantes de fase aguda en la sepsis.

In 71 patients with fever and bacteremia without complications, a prospective study of acute-phase reactants is done. Raises in haptoglobin, ceruloplasmin, alpha-1-antitrypsin, protein C, beta-2-microglobulin, IgA and ferritin serum levels, together with leucocytosis and GSR, were very significant when diagnosis was done. Fibronectin, sideremia and transferrin were lowered. After 3 and 6 days of treatment haptoglobins, alpha-1-antitrypsin, protein C, ferritin, leucocytosis and GSR are lowered, while immunoglobulins, sideremia, transferrin and fibronectin raised, the latter until normalization. Fibronectin as well as changes in iron metabolism were very reliable parameters of inflammation and favorable evolution.

Niveles de factor VIII coagulante en donantes de sangre según el tipo sanguíneo ABO / Level of factor VIII coagulant in blood donors according to ABO blood type

Se estudió la actividad del factor VIII coagulante en individuos sanos clasificados según los grupos sanguíneos, con el fin de obtener valores normales para contribuir a un mejor diagnóstico de laboratorio en pacientes con problemas hemorragíparos. Se estudiaron 128 dadores de sangre, cuyas edades variaron entre 18 y 59 años, seleccionados según las normas de los Bancos de Sangre. Se determinó el Factor VIII coagulante (FVIII:C), usando la técnica de Biggs y col. en una etapa y el grupo sanguíneo ABO por métodos convencionales. Los valores de referencia del FVIII:C fueron de 35 por ciento para los individuos tipo O y de 50 por ciento para los sujetos tipo A, B y AB. estos valores permitirán mejorar el diagnóstico de laboratorio y el tratamiento con crioprecipitados en pacientes con enfermedades hemorragíparas, como hemofilia clásica y la enfermedad de Von Willebrand

Niveles de FvW:Ag en individuos de grupo sanguíneo 0 / FvW antigen serum levels in 0 blood group individuals

Dada la relación entre el grupo sanguíneo ABO y los niveles de FvW:Ag en 50 dadores de sangre tipo 0, mediante inmunoelectroforesis, con el objeto de obtener valores normales de referencia. El 22% de los dadores presentó niveles de FvW:Ag moderadamente más bajos que el intervalo normal de referencia (INR), 0,62-1,5 U/ml. Obtuvimos en el grupo dadores un promedio de 0.89 ñ 0,48 U/ml (2SD), y con ello un intervalo de 0,41-1,37 U/ml (IGD). Seleccionamos 30 pacientes grupo sanguíneo 0 con enfermedad de Von Willebrand tipo I (EvW), grupo vW, para conocer cómo se distribuían sus concentraciones de FvW:Ag en ambos intervalos. Obtuvimos un 86,6% (n =26) de pacientes con niveles de FvW:Ag dentro del IGD, en cambio sólo un 36,6% (n =11) de estos pacientes tenían sus concentraciones de FvW:Ag dentro del INR. Este hecho resultó significativo por la prueba chi cuadrado. Aunque estas observaciones fueron con un n relativamente pequeño, nos sugieren que a individuos con problemas hemorragíparos grupo sanguíneo 0, deberíamos estudiarlos con un control normal del mismo grupo; esto ayudaría sobre todo en aquellos casos donde se trata de diagnosticar formas leves (las más frecuentes) de la EvW por el laboratorio

[Von Willebrand's disease in the IX Region of Chile]. / Enfermedad de von Willebrand en la IX Region de Chile.

Bleeding disorders are frequent indications for reference to Hematologic Clinics. Won Willebrand's disease (vWD) is one of the commonest of inheritable hemorrhagic diathesis. In order to evaluate the frequency and clinical characteristics of vWD in the IX Region of Chile, we performed a clinical and laboratory investigation in 132 patients, children and adults, over a period of 3 years: 1983-1985. Within this group there was 26 close relatives. The laboratory tests used for the diagnosis were: bleeding time, factor VIII, von Willebrand factor and ristocetin cofactor. Diagnosis of vWD was made in 83 cases, most of them presenting the mild form of the disease. Two children had the severe form. The estimated prevalence of vWD in symptomatic patients in the IX Region of Chile is at least 113 per million, which makes it 3 or 4 times more frequent than hemophilia. vWD is observed at a much lower rate in mapuche than in caucasian population. The symptoms and their frequency were: post partum bleeding 75%, dental extraction bleeding 65%, surgical bleeding 65%, epistaxis 63%, menorrhagia 54%, easy bruising 45%, deep hematomas 8% and petechiae 5%. Five cases were asymptomatic. The bleeding time was the test most frequently abnormal: 72/83 cases (87%).